Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Partial Hepatectomy for Metastatic Carcinoma S. Arthur Localio To cite this article: S. Arthur Localio (1976) Partial Hepatectomy for Metastatic Carcinoma, Hospital Practice, 11:3, 60-68, DOI: 10.1080/21548331.1976.11706914 To link to this article: http://dx.doi.org/10.1080/21548331.1976.11706914
Published online: 06 Jul 2016.
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Date: 26 August 2017, At: 10:24
Partial Hepatectomy for Metastatic Carcinoma
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
S. ARTHUR LOCALIO
NewYorkUniversity
Three years after colonic resection for a rectal carcinoma, the patient evinced some weight loss and alkaline phosphatase elevation. Detailed workup revealed what appeared to be a solitary, well-defined metastatic lesion of the right hepatic lobe. Since the patient could be considered a good candidate for surgery, and given the grim prognosis of alternative approaches, hepatic lobectomy was carried out, as described here.
Case Presentation In October of 1975 a 58-year-old attorney was admitted to New York University Hospital for possible right hepatic lobectomy to remove what was presumed, on the basis of past history and preliminary workup, to be a single, welllocalized metastatic lesion secondary to carcinoma of the colon, which we had resected some three years earlier. The earlier procedure, abdominosacral resection with colostomy and subsequent closure, had removed a carcinoma from the mid rectum, and the postoperative course had been uneventful. About four months before the current hospitalization, when we saw the patient for routine follow-up, he mentioned in an offhand way that he had lost six pounds during the preceding three weeks without any special effort. A blood sugar determination at this time was elevated, indicating that a borderline diabetes, originally diagnosed in 197~. had progressed. The alkaline phosphatase level was slightly elevated; the lactic dehydrogenase was within normal limits. More extensive study was advised. A barium enema was interpreted as normal. Repetition of the liver function tests again showed an elevated alkaline phosphatase, and, in addition, a liver scan demonstrated a filling defect suggestive of the presence of a mass in the right lobe. On this basis, it was recommended that the patient enter the hospital for liver biopsy to assess the possibility of metastatic disease. At admission the patient seemed well nourished and in no apparent distress. His weight loss had not progressed since we had last seen him. In general the physical ex-
Dr. Localio is Professor of Surge'll and johnson and johnson Distinguished Professor of Surge'lJ, New York University.
6o
Hospital Practice March 19-,6
amination was unremarkable. The abdomen was soft and nontender, and the liver was depressed ~ em below the right costal margin. TI1ere were no signs of masses or organomegaly. Aside from the earlier surgery for carcinoma, the patient's history did not shed any light on his current problems. He had had a T&A as well as nephritis as a child, hepatitis without sequelae decades before, and a ruptured appendix some six or seven years ago. TI1ere was no suggestion that alcohol intake was a problem. Laboratory studies suggested that liver function had not been greatly compromised: The alkaline phosphatase level was 100, the lactic acid dehydrogenase, serum bilirubin, and SCOT were all within normal limits. Since the liver scan had suggested a well-localized mass in the right lobe, with no hint of lesions elsewhere in the liver, it was decided to proceed with the biopsy. This is not always undertaken in such cases, since biopsy carries some unknown risk of seeding a malignancy. Yet, since histologic assessment is the ultimate determinant in the diagnosis of malignancy, biopsy has powerful attractions if it can be justified. In this case, we knew that the patient had had colon cancer, in which metastases to the liver are quite common. The lesion also appeared to be well localized near the border of the right lobe. We accordingly felt that the value of positive diagnosis outweighed any theoretical risks. The biopsy showed neoplastic tissue composed of small, poorly formed glands in fibrous stroma. The glands themselves were lined with pleomorphic cells, often basal,. with hyperchromatic nuclei. There was diffuse fatty change, with many glycogen nuclei, in the hepatic parenchyma. The histologic diagnosis was secondary adenocarcinoma. Since it was essential to obtain the clearest possible delineation of the lesion, celiac and superior mesenteric arteriography was carried out. The hepatic angiogram, in our
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
view, is the single most definitive modality for preoperative assessment of such lesions. It not only clearly delineates their extent and (usually) allows one to make a reasonable assessment of their nature but also provides the surgeon with valuable information concerning possible vascular anoma lies in an area where anomalies are the rule. The angiogram confirmed the presence of a large, solitary lesion in the superior anterior segment of the right hepatic lobe, with no indication of extension to either the inferior segment of the right lobe or the left lobe. The pancreas and spleen appeared !lormal. Study of coagulation factors showed that bleeding time, platelet count, prothrombin and partial thromboplastin time, and fibrinogen were all normal. Levels of factors II, V, and VII to X were higher than normal. Data on the various clotting factors and on the integrity of the entire clotting mechanism are of crucial importance·in any procedure involving insult to the liver. Any such procedure may activate the fibrinolytic system, depleting fibrinogen and resulting in hemorrhage. This has been known to occur even in patients with an intact clotting mechanism before surgery. The patient's electrocardiogram and chest x-rays were also normal, as was kidney function. Pulmonary and cardiac function are, of course, important parameters in any patient who is to undergo general anesthesia, but in the case of liver resection some added attention must be given to both, since hypotensive anesthesia is used. By reducing the blood pressure in a highly vascularized area; such anesthesia makes the operation much simpler, more accurate, and spares blood loss. On balance, this patient was a good candidate for hepatic lobectomy. He had a single metastatic mass and good cardiac and pulmonary functions. His blood-clotting mechanism was in good order and, although the procedure itself would disturb it, he did not have any bizarre coagulation defects that would need to be reckoned with at the outset. Also, he had no known metastases to other areas of the body; accordingly, resection of the hepatic lesion might prove effective. Also in his favor was the fact that the metastasis
was not detected until three years after the original cancer resection; this bespoke a slow-growing process. In sum, the patient remained a basically healthy individual despite his malignancy and could be expected to withstand reasonably well the extensive procedure required to remove the metastatic lesion. In this patient, then, as in so many others with localized hepatic lesions, malignant or otherwise, that threaten liver function and ultimately life itself, lobectomy appeared to be the most satisfactory of the few choices open. The expectation was that within months his hepatic function would be back to normal and that within a year his total liver mass should more or less equal its preoperative state. His longterm survival would probably depend upon the fundamental nature of the
malignant process that produced the primary cancer in the colon, but at least progression of the disease could be interrupted for a time and possibly even aborted by excision of the liver metastasis. Even though the procedure must be recognized as formidable, operative mortality has been reduced to less than 4%. Five-year survival following resection for both carcinoma of the colon and subsequent metastasis to the liver has been reported to be 21%. The risks of the right hepatic lobectomy, the probable morbidity to be encountered, the chances of long-term survival, both with and without the procedure, were all carefully explained to the patient. He elected to undergo the operation and it was carried out as described in the following pages.
As indicated in the drawing above, the metastatic lesion in the liver was confined to the medial suJJerior part of the right lobe. The patient's right side was tilted upward about 30• to facilitate the procedure and an upper abdominal oblique incision was made, as .\hown. The abdomen was explored, the lesion was deemed resectable, and the incision was extended across the right costal margin and into the thorax in the ninth intercostal Sl>ace to the midaxillary line. Hospital Practice March 1976
61
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In photo 1 the incision is shown being extended into the chest, affording wide access to the liver. With the greater exposure provided by the completed incision, an extension of the tumor into the underside of the diaphragm is discovered. A .~eg ment of diaphragm about 4 em in diameter is excised a11d is left attached to the tumor and liver (photo 2). Next, the ligamentous attachments of the liver are all carefully divided so that the organ can be rolled over to penult approach to the hepatic triad, the vena cava, and the hepatic veins. The porta hepatis is see11 iiiJJhoto 3, as the task of identifyir~g the right hepatic artery, the cystic duct, the common duct, and the JlOrtal vein gets under way.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
The drawing at left shows the anatomic juxtaposition of the inflow to the right lobe; it must be secured before he,wtic resection can begin. Next, the cystic artery is identified and the right hepatic artery dissected free and surrounded with a tie. The cystic duct is then identified, after which it is ligated and divided (photo 4). The next step is to double-ligate and divide the right hepatic artery, which lay under the common duct. The common duct is then dissected out and the right hepatic duct located. The common duct was found to be about 8 mm in diameter and showed no signs of inflammatory disease. To clearly demonstrate the hepatic ducts a choledochotomy was performed. This done, the left duct is intubated, the right hepatic duct ligated, and aT-tube placed (photo 5). The choledochotomy is then closed with a running 4/0 chromic stitch.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
To complete control of the hepatic triad, the right portal vein is isolated (as shown in drawing above), then divided and oversewn with a running stitch (photo 6). The completed dissection of the triad, with the cystic duct and inflow to the right lobe divided and ligated, is seen in photo 7. The forceps at left of the picture rest on the severed cystic duct; the other forceps points to the cystic artery, and the "peanut" rests on the lowermost portion of the right lobe. The long limb of the T-tube is visible at the top. There is some controversy as to whether the common duct should be opened and a T-tube inserted in this type of procedure. In this patient (as in many if not most others), it was felt that the T-tube would help speed the procedure, the reason being that lt enables the surgeon to know at all times e:tactly where the left duct b. It is reassuring to the surgeon to know polltoperattvely that the remaining liver fragment b producing bile.
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Once the hepatic triad has been secured, attention is turned to the retroperitoneal hepatic outflow into the vena cava. First the liver is rolled medially and the inferior vena cava exposed. All the hepatic veins that leave the right lobe of the liver to debouch directly into the vena cava must be isolated and secured. Usually there are three major hepatic veins from the posterior aspect of the liver, which ordinarily are not hard to find. But in addition there may be many other (up to 20 or 25) smaller veins, each of which must be dissected out and secured separately. Photo 8 shows one of the larger veins being divided after it has been clamped at its juncture with the vena cava. Next, the point of tmtry to the vena cava is oversewn with a running stitch (photo 9). Since this patient has aiJOut 25 smaller veins coming from the liver, the freeing of the retroperitoneal aspect proceeds slowly. As the dissection progresses upward, the large right hepatic vein is exposed and divided over vascular clamps. By this time the inflow and outflow from the right liver are ostensibly secure and, in any event, the right lobe has begun to show signs of devitalization. As it is rolled off the vena cava, however, just prior to the start of the resection as such, an anomalous portal vein to the right lobe is found, clamped, and oversewn. Photo 10 and the dflJwing at left below show the securing completed.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
Attention is now tumed to the actual lobectomy. A line of resection to the right of the falciform ligament in the medial segment of the left lobe is to be established. In other words, an extended rather than a simple right hepatectomy will be done in order to separate the malignant area adequately from healthy liver. When a Lin clamp is positioned between the porta hepatis and the superior surface to aid hemostasis, it is found that it does not compress the liver parenchyma adequately because the diameter of the closed clamp is slightly larger than the thickness of the medial segment of the left lobe. A smaller clamp is sub~tituted and the liver is then incised with a knife (photo 11) and theresection proceeds as shown in the series of drawings above. Bleeding points and bile ducts from the left lobe are oversewn. Since the clamp still cannot be compressed enough to give adequate hemostasis, it is decided to proceed with the resection by using the finger-fracture technique: the liver is compressed bit-by-bit between the fingers, and the vessell or bile ducts encountered are clamped, divided, and secured. As the dissection progresses towards the vena cava inferiorly and posteriorly, the middle hepatic vein and its juncture with the left hepatic vein is encountered. It is carefully clamped and oversewn. This done, the remainder of the liver parenchyma is readily divided by finger fracttire and the lobe removed. The cut face of the liver remnant· is over8ewn, using edge-to-edge mattress sutures (photo 12). Oxycel cotton is temporarily placed over the oversewn face for final hemostasis. When sectioned, the specimen (photo 13) showed the tumor to measure about 5 x 6 x 6 em overall. Blood loss was put at 1,500 cc.
Postoperative Note
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Postoperatively, the patient had a moderate amount of bleeding from drains placed in the right upper quadrant along the cut edge of the liver. On the first postoperative day his coagulation profile was abnormal: prothrombin time was 14/12, partial thromboplastin time was 62/40; all factors assayed were between 6o% and 72%. The following day the prothrombin time was 17/I 3, factors V and VII to X were 28% and 29% of normal. On the third postoperative day, these factors fell to 15% to 17% of normal and the prothrombin time was 18/I 3. Fibrinogen and other coagulation factors were normal, and the prothrombin and re-
The Case in Context As the safety and feasibility of extensive liver resection have become established in recent years, the procedure has been performed with increasing frequency. Omitting the partial resections undertaken after trauma, when heroic measures may be needed if the patient is to survive, most partial hepatectomies are probably now being done for primary malignant tumors. With secondary liver cancer, the procedure is usually confined to metastases from colon cancer, as in the patient presented. Another rare indication is echinococcal cyst disease of the liver, for which partial hepatectomy may be the only practicable modality. In patients with the carcinoid syndrome, partial hepatectomy is occasionally undertaken for palliation. The procedure has been much more widely used in the Orient, where hepatoma is a more common disease. The largest series of partial hepatectomies arc probably those reported by surgeons in Hong Kong, Taiwan, and the Peoples' Republic of China. Experience has thus demonstrated that partial hepatectomy is a feasible technique, and that in many patients it may be the only modality of promise. The main questions would therefore seem to be: Who should have it? How should it be done and by whom? As to the first, we have already indicated that the patient must meet at least two basic criteria: he must have 1) are-' sectable hepatic lesion or lesions, and 2) a basically healthy liver remnant, one capable of regeneration. Experience reported by Lin and others indicates that cirrhotics invariably do poorly following lobectomy. It is obvious also that a procedure of this magnitude should not be attempted in the patient with an underlying condition that would limit life expectancy, with or without the hepatic lesion. But if the patient has disease limited to one part of the liver and the procedure appears technically feasible on other grounds, partial hepatectomy should probably be con-
maining abnormalities recovered in the ensuing days. On the first postoperative day, the patient was jaundiced. There was scanty T-tube drainage of thin, lightgreen bile. Bilirubin rose to 20, then gradually improved. The drain yielded a moderate amount of old blood and drainage was widened when the patient became febrile. The drain fluid grew an enterobacter resistant to all antibiotics but polymyxin, but with improved drainage the temperature fell and the drug was not used. The patient was discharged 45 days postoperatively, with T-tube removed and the wound healed. The coagulation profile was normal and the liver and spleen scan showed that the liver remnant had begun to enlarge.
sidered. As was noted in the opening section, the overall salvage rate (excluding operative deaths) among patients with metastasis from colon cancer is :2.1 %. In primary liver cancer, a review by Foster indicates that the five-year survival rate after lobectomy is 36% (again excluding operative deaths) for Occidentals. The rate for Orientals is only 6%. ljlis figure reflects the fact that the proportion of cirrhotics among those who had the operation was high. As with any procedure, the safety of partial hepatectomy has improved with experience, with the development of special instrumentation, and with increased understanding of the basic physiology and pathophysiology of the liver. As noted earlier, operative mortality is now around 4% in properly selected patients. An important safety factor for .liver resection has been the hematologists' increasing knowledge of and ability to manipulate the coagulation mechanism. Another very important factor in success is the quality of the anesthesia. The hypotensive anesthesia preferred spares the patient blood loss and makes the surgeon's task e.1sier. Improvements in a number of diagnostic modalities have also contributed to the broadening of the indications. The diagnostic process begins with various hepatic function tests. If the results, and perhaps other factors, are enough to arouse suspicion, a liver scan is the logical next step. If it suggests a solitary mass, one should then do hepatic artery angiography of both lobes of the liver. This, as noted, will give a precise idea of the size, location, vascularity, and probable nature of the lesion. Finally, one should also point out that modalities, such as tomography, that allow one to rule out metastases in other areas have also contributed to the success rate of partial hepatectomy. It cannot be overemphasized that one must not overlook, say, a small pulmonary lesion. Certainly it would be pointless to resect 75% of the liver to remove metastases while leaving a lesion elsewhere. Turning to techniques as such: those employed may differ in minor ways but all have the same aim - to mobilize Hospital Practice Man:h 1976
67
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The selective .~uperior-mesenteric arteriogram of the patient whose case ts presented clearly deltneated a single large lesion tn the superior segment of the right hepatic lobe. the liver and to resect the offending lobe as bloodlessly and atraumatically as possible. Since the procedure is tedious and leaves little room for error, it should be done systematically. The approach we have found most
satisfactory is the one demonstrated in the case presented here. In general, we always begin by mobilizing the ligamentous attachments of the liver. Next, we control first the inflow to, then the outflow from, the organ,
Selected Readings Dillard BM: Experience with twenty-six hepatic lobectomies and extensive hepatic resections. Surg Gynecol Obstet ll9(l):l49. 1¢9 Foster JH: Survival after liver resection. Cancer z6:493, 1970 Lin TY: A simplified technique for hepatic resection: in the crush method. Ann Surg 11lo:zH5, 1974
Lin TY: Results in .107 hepatic lobectomies with a preliminary report on the use of the clamp to reduce blood loss. Ann Surg 1n;413, 1973 Lin TY, Chin CC: Metabolic function and regeneration in cirrhotic livers after hepatic lobectomy. Ann Surg 16z:959, 1965 Longmire WP: Hepatic resection. Adv Surg 8:z9, 1974 Merindino I
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Partial Hepatectomy for Metastatic Carcinoma S. Arthur Localio To cite this article: S. Arthur Localio (1976) Partial Hepatectomy for Metastatic Carcinoma, Hospital Practice, 11:3, 60-68, DOI: 10.1080/21548331.1976.11706914 To link to this article: http://dx.doi.org/10.1080/21548331.1976.11706914
Published online: 06 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [Australian Catholic University]
Date: 26 August 2017, At: 10:24
Partial Hepatectomy for Metastatic Carcinoma
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
S. ARTHUR LOCALIO
NewYorkUniversity
Three years after colonic resection for a rectal carcinoma, the patient evinced some weight loss and alkaline phosphatase elevation. Detailed workup revealed what appeared to be a solitary, well-defined metastatic lesion of the right hepatic lobe. Since the patient could be considered a good candidate for surgery, and given the grim prognosis of alternative approaches, hepatic lobectomy was carried out, as described here.
Case Presentation In October of 1975 a 58-year-old attorney was admitted to New York University Hospital for possible right hepatic lobectomy to remove what was presumed, on the basis of past history and preliminary workup, to be a single, welllocalized metastatic lesion secondary to carcinoma of the colon, which we had resected some three years earlier. The earlier procedure, abdominosacral resection with colostomy and subsequent closure, had removed a carcinoma from the mid rectum, and the postoperative course had been uneventful. About four months before the current hospitalization, when we saw the patient for routine follow-up, he mentioned in an offhand way that he had lost six pounds during the preceding three weeks without any special effort. A blood sugar determination at this time was elevated, indicating that a borderline diabetes, originally diagnosed in 197~. had progressed. The alkaline phosphatase level was slightly elevated; the lactic dehydrogenase was within normal limits. More extensive study was advised. A barium enema was interpreted as normal. Repetition of the liver function tests again showed an elevated alkaline phosphatase, and, in addition, a liver scan demonstrated a filling defect suggestive of the presence of a mass in the right lobe. On this basis, it was recommended that the patient enter the hospital for liver biopsy to assess the possibility of metastatic disease. At admission the patient seemed well nourished and in no apparent distress. His weight loss had not progressed since we had last seen him. In general the physical ex-
Dr. Localio is Professor of Surge'll and johnson and johnson Distinguished Professor of Surge'lJ, New York University.
6o
Hospital Practice March 19-,6
amination was unremarkable. The abdomen was soft and nontender, and the liver was depressed ~ em below the right costal margin. TI1ere were no signs of masses or organomegaly. Aside from the earlier surgery for carcinoma, the patient's history did not shed any light on his current problems. He had had a T&A as well as nephritis as a child, hepatitis without sequelae decades before, and a ruptured appendix some six or seven years ago. TI1ere was no suggestion that alcohol intake was a problem. Laboratory studies suggested that liver function had not been greatly compromised: The alkaline phosphatase level was 100, the lactic acid dehydrogenase, serum bilirubin, and SCOT were all within normal limits. Since the liver scan had suggested a well-localized mass in the right lobe, with no hint of lesions elsewhere in the liver, it was decided to proceed with the biopsy. This is not always undertaken in such cases, since biopsy carries some unknown risk of seeding a malignancy. Yet, since histologic assessment is the ultimate determinant in the diagnosis of malignancy, biopsy has powerful attractions if it can be justified. In this case, we knew that the patient had had colon cancer, in which metastases to the liver are quite common. The lesion also appeared to be well localized near the border of the right lobe. We accordingly felt that the value of positive diagnosis outweighed any theoretical risks. The biopsy showed neoplastic tissue composed of small, poorly formed glands in fibrous stroma. The glands themselves were lined with pleomorphic cells, often basal,. with hyperchromatic nuclei. There was diffuse fatty change, with many glycogen nuclei, in the hepatic parenchyma. The histologic diagnosis was secondary adenocarcinoma. Since it was essential to obtain the clearest possible delineation of the lesion, celiac and superior mesenteric arteriography was carried out. The hepatic angiogram, in our
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
view, is the single most definitive modality for preoperative assessment of such lesions. It not only clearly delineates their extent and (usually) allows one to make a reasonable assessment of their nature but also provides the surgeon with valuable information concerning possible vascular anoma lies in an area where anomalies are the rule. The angiogram confirmed the presence of a large, solitary lesion in the superior anterior segment of the right hepatic lobe, with no indication of extension to either the inferior segment of the right lobe or the left lobe. The pancreas and spleen appeared !lormal. Study of coagulation factors showed that bleeding time, platelet count, prothrombin and partial thromboplastin time, and fibrinogen were all normal. Levels of factors II, V, and VII to X were higher than normal. Data on the various clotting factors and on the integrity of the entire clotting mechanism are of crucial importance·in any procedure involving insult to the liver. Any such procedure may activate the fibrinolytic system, depleting fibrinogen and resulting in hemorrhage. This has been known to occur even in patients with an intact clotting mechanism before surgery. The patient's electrocardiogram and chest x-rays were also normal, as was kidney function. Pulmonary and cardiac function are, of course, important parameters in any patient who is to undergo general anesthesia, but in the case of liver resection some added attention must be given to both, since hypotensive anesthesia is used. By reducing the blood pressure in a highly vascularized area; such anesthesia makes the operation much simpler, more accurate, and spares blood loss. On balance, this patient was a good candidate for hepatic lobectomy. He had a single metastatic mass and good cardiac and pulmonary functions. His blood-clotting mechanism was in good order and, although the procedure itself would disturb it, he did not have any bizarre coagulation defects that would need to be reckoned with at the outset. Also, he had no known metastases to other areas of the body; accordingly, resection of the hepatic lesion might prove effective. Also in his favor was the fact that the metastasis
was not detected until three years after the original cancer resection; this bespoke a slow-growing process. In sum, the patient remained a basically healthy individual despite his malignancy and could be expected to withstand reasonably well the extensive procedure required to remove the metastatic lesion. In this patient, then, as in so many others with localized hepatic lesions, malignant or otherwise, that threaten liver function and ultimately life itself, lobectomy appeared to be the most satisfactory of the few choices open. The expectation was that within months his hepatic function would be back to normal and that within a year his total liver mass should more or less equal its preoperative state. His longterm survival would probably depend upon the fundamental nature of the
malignant process that produced the primary cancer in the colon, but at least progression of the disease could be interrupted for a time and possibly even aborted by excision of the liver metastasis. Even though the procedure must be recognized as formidable, operative mortality has been reduced to less than 4%. Five-year survival following resection for both carcinoma of the colon and subsequent metastasis to the liver has been reported to be 21%. The risks of the right hepatic lobectomy, the probable morbidity to be encountered, the chances of long-term survival, both with and without the procedure, were all carefully explained to the patient. He elected to undergo the operation and it was carried out as described in the following pages.
As indicated in the drawing above, the metastatic lesion in the liver was confined to the medial suJJerior part of the right lobe. The patient's right side was tilted upward about 30• to facilitate the procedure and an upper abdominal oblique incision was made, as .\hown. The abdomen was explored, the lesion was deemed resectable, and the incision was extended across the right costal margin and into the thorax in the ninth intercostal Sl>ace to the midaxillary line. Hospital Practice March 1976
61
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
In photo 1 the incision is shown being extended into the chest, affording wide access to the liver. With the greater exposure provided by the completed incision, an extension of the tumor into the underside of the diaphragm is discovered. A .~eg ment of diaphragm about 4 em in diameter is excised a11d is left attached to the tumor and liver (photo 2). Next, the ligamentous attachments of the liver are all carefully divided so that the organ can be rolled over to penult approach to the hepatic triad, the vena cava, and the hepatic veins. The porta hepatis is see11 iiiJJhoto 3, as the task of identifyir~g the right hepatic artery, the cystic duct, the common duct, and the JlOrtal vein gets under way.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
The drawing at left shows the anatomic juxtaposition of the inflow to the right lobe; it must be secured before he,wtic resection can begin. Next, the cystic artery is identified and the right hepatic artery dissected free and surrounded with a tie. The cystic duct is then identified, after which it is ligated and divided (photo 4). The next step is to double-ligate and divide the right hepatic artery, which lay under the common duct. The common duct is then dissected out and the right hepatic duct located. The common duct was found to be about 8 mm in diameter and showed no signs of inflammatory disease. To clearly demonstrate the hepatic ducts a choledochotomy was performed. This done, the left duct is intubated, the right hepatic duct ligated, and aT-tube placed (photo 5). The choledochotomy is then closed with a running 4/0 chromic stitch.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
To complete control of the hepatic triad, the right portal vein is isolated (as shown in drawing above), then divided and oversewn with a running stitch (photo 6). The completed dissection of the triad, with the cystic duct and inflow to the right lobe divided and ligated, is seen in photo 7. The forceps at left of the picture rest on the severed cystic duct; the other forceps points to the cystic artery, and the "peanut" rests on the lowermost portion of the right lobe. The long limb of the T-tube is visible at the top. There is some controversy as to whether the common duct should be opened and a T-tube inserted in this type of procedure. In this patient (as in many if not most others), it was felt that the T-tube would help speed the procedure, the reason being that lt enables the surgeon to know at all times e:tactly where the left duct b. It is reassuring to the surgeon to know polltoperattvely that the remaining liver fragment b producing bile.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
Once the hepatic triad has been secured, attention is turned to the retroperitoneal hepatic outflow into the vena cava. First the liver is rolled medially and the inferior vena cava exposed. All the hepatic veins that leave the right lobe of the liver to debouch directly into the vena cava must be isolated and secured. Usually there are three major hepatic veins from the posterior aspect of the liver, which ordinarily are not hard to find. But in addition there may be many other (up to 20 or 25) smaller veins, each of which must be dissected out and secured separately. Photo 8 shows one of the larger veins being divided after it has been clamped at its juncture with the vena cava. Next, the point of tmtry to the vena cava is oversewn with a running stitch (photo 9). Since this patient has aiJOut 25 smaller veins coming from the liver, the freeing of the retroperitoneal aspect proceeds slowly. As the dissection progresses upward, the large right hepatic vein is exposed and divided over vascular clamps. By this time the inflow and outflow from the right liver are ostensibly secure and, in any event, the right lobe has begun to show signs of devitalization. As it is rolled off the vena cava, however, just prior to the start of the resection as such, an anomalous portal vein to the right lobe is found, clamped, and oversewn. Photo 10 and the dflJwing at left below show the securing completed.
Downloaded by [Australian Catholic University] at 10:24 26 August 2017
Attention is now tumed to the actual lobectomy. A line of resection to the right of the falciform ligament in the medial segment of the left lobe is to be established. In other words, an extended rather than a simple right hepatectomy will be done in order to separate the malignant area adequately from healthy liver. When a Lin clamp is positioned between the porta hepatis and the superior surface to aid hemostasis, it is found that it does not compress the liver parenchyma adequately because the diameter of the closed clamp is slightly larger than the thickness of the medial segment of the left lobe. A smaller clamp is sub~tituted and the liver is then incised with a knife (photo 11) and theresection proceeds as shown in the series of drawings above. Bleeding points and bile ducts from the left lobe are oversewn. Since the clamp still cannot be compressed enough to give adequate hemostasis, it is decided to proceed with the resection by using the finger-fracture technique: the liver is compressed bit-by-bit between the fingers, and the vessell or bile ducts encountered are clamped, divided, and secured. As the dissection progresses towards the vena cava inferiorly and posteriorly, the middle hepatic vein and its juncture with the left hepatic vein is encountered. It is carefully clamped and oversewn. This done, the remainder of the liver parenchyma is readily divided by finger fracttire and the lobe removed. The cut face of the liver remnant· is over8ewn, using edge-to-edge mattress sutures (photo 12). Oxycel cotton is temporarily placed over the oversewn face for final hemostasis. When sectioned, the specimen (photo 13) showed the tumor to measure about 5 x 6 x 6 em overall. Blood loss was put at 1,500 cc.
Postoperative Note
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Postoperatively, the patient had a moderate amount of bleeding from drains placed in the right upper quadrant along the cut edge of the liver. On the first postoperative day his coagulation profile was abnormal: prothrombin time was 14/12, partial thromboplastin time was 62/40; all factors assayed were between 6o% and 72%. The following day the prothrombin time was 17/I 3, factors V and VII to X were 28% and 29% of normal. On the third postoperative day, these factors fell to 15% to 17% of normal and the prothrombin time was 18/I 3. Fibrinogen and other coagulation factors were normal, and the prothrombin and re-
The Case in Context As the safety and feasibility of extensive liver resection have become established in recent years, the procedure has been performed with increasing frequency. Omitting the partial resections undertaken after trauma, when heroic measures may be needed if the patient is to survive, most partial hepatectomies are probably now being done for primary malignant tumors. With secondary liver cancer, the procedure is usually confined to metastases from colon cancer, as in the patient presented. Another rare indication is echinococcal cyst disease of the liver, for which partial hepatectomy may be the only practicable modality. In patients with the carcinoid syndrome, partial hepatectomy is occasionally undertaken for palliation. The procedure has been much more widely used in the Orient, where hepatoma is a more common disease. The largest series of partial hepatectomies arc probably those reported by surgeons in Hong Kong, Taiwan, and the Peoples' Republic of China. Experience has thus demonstrated that partial hepatectomy is a feasible technique, and that in many patients it may be the only modality of promise. The main questions would therefore seem to be: Who should have it? How should it be done and by whom? As to the first, we have already indicated that the patient must meet at least two basic criteria: he must have 1) are-' sectable hepatic lesion or lesions, and 2) a basically healthy liver remnant, one capable of regeneration. Experience reported by Lin and others indicates that cirrhotics invariably do poorly following lobectomy. It is obvious also that a procedure of this magnitude should not be attempted in the patient with an underlying condition that would limit life expectancy, with or without the hepatic lesion. But if the patient has disease limited to one part of the liver and the procedure appears technically feasible on other grounds, partial hepatectomy should probably be con-
maining abnormalities recovered in the ensuing days. On the first postoperative day, the patient was jaundiced. There was scanty T-tube drainage of thin, lightgreen bile. Bilirubin rose to 20, then gradually improved. The drain yielded a moderate amount of old blood and drainage was widened when the patient became febrile. The drain fluid grew an enterobacter resistant to all antibiotics but polymyxin, but with improved drainage the temperature fell and the drug was not used. The patient was discharged 45 days postoperatively, with T-tube removed and the wound healed. The coagulation profile was normal and the liver and spleen scan showed that the liver remnant had begun to enlarge.
sidered. As was noted in the opening section, the overall salvage rate (excluding operative deaths) among patients with metastasis from colon cancer is :2.1 %. In primary liver cancer, a review by Foster indicates that the five-year survival rate after lobectomy is 36% (again excluding operative deaths) for Occidentals. The rate for Orientals is only 6%. ljlis figure reflects the fact that the proportion of cirrhotics among those who had the operation was high. As with any procedure, the safety of partial hepatectomy has improved with experience, with the development of special instrumentation, and with increased understanding of the basic physiology and pathophysiology of the liver. As noted earlier, operative mortality is now around 4% in properly selected patients. An important safety factor for .liver resection has been the hematologists' increasing knowledge of and ability to manipulate the coagulation mechanism. Another very important factor in success is the quality of the anesthesia. The hypotensive anesthesia preferred spares the patient blood loss and makes the surgeon's task e.1sier. Improvements in a number of diagnostic modalities have also contributed to the broadening of the indications. The diagnostic process begins with various hepatic function tests. If the results, and perhaps other factors, are enough to arouse suspicion, a liver scan is the logical next step. If it suggests a solitary mass, one should then do hepatic artery angiography of both lobes of the liver. This, as noted, will give a precise idea of the size, location, vascularity, and probable nature of the lesion. Finally, one should also point out that modalities, such as tomography, that allow one to rule out metastases in other areas have also contributed to the success rate of partial hepatectomy. It cannot be overemphasized that one must not overlook, say, a small pulmonary lesion. Certainly it would be pointless to resect 75% of the liver to remove metastases while leaving a lesion elsewhere. Turning to techniques as such: those employed may differ in minor ways but all have the same aim - to mobilize Hospital Practice Man:h 1976
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The selective .~uperior-mesenteric arteriogram of the patient whose case ts presented clearly deltneated a single large lesion tn the superior segment of the right hepatic lobe. the liver and to resect the offending lobe as bloodlessly and atraumatically as possible. Since the procedure is tedious and leaves little room for error, it should be done systematically. The approach we have found most
satisfactory is the one demonstrated in the case presented here. In general, we always begin by mobilizing the ligamentous attachments of the liver. Next, we control first the inflow to, then the outflow from, the organ,
Selected Readings Dillard BM: Experience with twenty-six hepatic lobectomies and extensive hepatic resections. Surg Gynecol Obstet ll9(l):l49. 1¢9 Foster JH: Survival after liver resection. Cancer z6:493, 1970 Lin TY: A simplified technique for hepatic resection: in the crush method. Ann Surg 11lo:zH5, 1974
Lin TY: Results in .107 hepatic lobectomies with a preliminary report on the use of the clamp to reduce blood loss. Ann Surg 1n;413, 1973 Lin TY, Chin CC: Metabolic function and regeneration in cirrhotic livers after hepatic lobectomy. Ann Surg 16z:959, 1965 Longmire WP: Hepatic resection. Adv Surg 8:z9, 1974 Merindino I
